A client diagnosed with end-stage kidney injury receives continuous ambulatory peritoneal dialysis (CAPD). The nurse observes that the dialysate drainage fluid is cloudy. What is the priority intervention?

Administer a bolus of IV normal saline as ordered

Flush the peritoneal catheter with normal saline

Assess the client for signs of infection

Continue to monitor the color of the dialysate

Answer and Explanation

The Correct Answer is C

Choice A reason: Administering IV normal saline addresses fluid volume deficits, not cloudy dialysate, which suggests peritonitis in CAPD. Saline does not treat infection or clarify drainage. Without addressing the potential infection, complications like sepsis or peritoneal membrane damage may occur, making this intervention irrelevant to the finding.

Choice B reason: Flushing the peritoneal catheter with saline risks introducing bacteria or dislodging clots, worsening potential infection. Cloudy dialysate indicates peritonitis, requiring assessment and likely antibiotics, not flushing. This action could compromise the catheter’s integrity and is not a standard intervention for suspected peritonitis in CAPD.

Choice C reason: Cloudy dialysate is a hallmark of peritonitis in CAPD, caused by bacterial infection. Assessing for fever, abdominal pain, or rebound tenderness confirms infection, enabling prompt antibiotic treatment. Early intervention prevents sepsis or peritoneal membrane scarring, which could necessitate dialysis modality change, making this the priority action.

Choice D reason: Continuing to monitor without assessing for infection delays treatment of potential peritonitis, a serious CAPD complication. Cloudy dialysate requires immediate evaluation, as untreated infection can lead to sepsis, peritoneal damage, or death. Passive monitoring risks patient safety, making this an inadequate response to a critical finding.

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Correct Answer is C

Explanation

Choice A reason: Renal failure impairs erythropoietin production, a hormone stimulating red blood cell synthesis, leading to anemia, not an increased red blood cell count. Reduced glomerular filtration exacerbates toxin accumulation, further suppressing bone marrow activity, making an elevated red blood cell count unlikely in this condition.

Choice B reason: In renal failure, kidneys fail to excrete potassium, leading to hyperkalemia, not decreased serum potassium. Hyperkalemia can cause cardiac arrhythmias due to altered membrane potentials. A decreased potassium level is more associated with conditions like diuretic use or vomiting, not renal failure.

Choice C reason: Increased serum creatinine is a hallmark of renal failure, as kidneys cannot filter creatinine, a muscle metabolism byproduct. Elevated levels reflect reduced glomerular filtration rate, indicating kidney dysfunction. This is a reliable marker for assessing renal failure severity and progression, making it an expected finding.

Choice D reason: Renal failure typically causes hypocalcemia, not increased serum calcium, due to impaired vitamin D activation and phosphate retention, which binds calcium. Hypercalcemia is rare and may occur in other conditions like hyperparathyroidism, not renal failure, where calcium homeostasis is disrupted by kidney dysfunction.

A. Sitting upright, uncrossed legs and arms, and at eye level B. Leaning forward with arms placed on a table sitting directly across from the client C. Sitting upright facing the client with both feet on the floor D. Turned slightly to the side of the client with arms folded across the chest

Correct Answer is A

Explanation

Choice A reason: Sitting upright with uncrossed limbs at eye level conveys openness and engagement. Uncrossed arms and legs signal non-defensiveness, while eye-level positioning fosters equality and trust. This posture aligns with therapeutic communication principles, promoting a safe, accepting environment for the client to express emotions freely.

Choice B reason: Leaning forward with arms on a table may appear intrusive or aggressive, potentially making the client feel uncomfortable. While engagement is intended, this posture can reduce personal space, disrupting the therapeutic environment and hindering the client’s sense of safety and acceptance during the conversation.

Choice C reason: Sitting upright with feet on the floor is neutral but less specific in conveying acceptance. Without mention of uncrossed arms or eye-level positioning, it may not fully signal openness. While not negative, it lacks the full therapeutic posture needed to maximize client comfort and trust.

Choice D reason: Turning to the side with folded arms suggests defensiveness or disengagement, which can make the client feel unaccepted or dismissed. This posture contradicts therapeutic communication principles, as it creates a barrier to open dialogue and may hinder the client’s willingness to share emotions.

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A client diagnosed with end-stage kidney injury receives continuous ambulatory peritoneal dialysis (CAPD). The nurse observes that the dialysate drainage fluid is cloudy. What is the priority intervention?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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